Hyperlipidemia - Endo

Question 1

Secondary hyperlipidemia causes

Answer 1

• diabetes
  
  • alcohol use
  • hypothyroidism
  • hypercortisolism
  • acromegaly
  • obesity
  • sedentary lifestyle
  • renal and liver problems
  • estrogens
  • thiazide diuretics
  • beta blockers

Question 2

Clinical Features of hyperlipidemia

Answer 2

• Typically no signs or symptoms
• Eruptive and tendinous xanthomas
• Nearly 2/3 of all people with xanthelasmas (these are the most common form of xanthomas that affect the eyelids) have normal lipid profiles
• Patients with severe hypercholesterolemia may develop premature arcus senilis (dementia)

Question 3

Lab Findings

Answer 3

• Order a FLP (fasting lipid profile); patients should fast for 9-12 hours prior to blood draw
• Screening of patients with no vascular disease and no risk factors should begin at the age of 35 for men and 45 for women
• Risk Factors include: family history, hypertension, smoking, diabetes, low HDL cholesterol, older age, and male gender
• Total Cholesterol 40 Women: >50
• Triglycerides: <70: CHD + diabetes + HTN

Question 4

ATP guidelines

Answer 4

Step 2: Identify presence of clinical atherosclerotic disease that confers high risk for coronary heart disease (CHD) events
-Clinical CHD
-Symptomatic carotid artery disease
-Peripheral arterial disease
-Abdominal aortic aneuysm
Step 3: Determine presence of major risk factors (exclude LDL choleserol)
-Cigarette Smoking
-Hypertension
-low HDL
-Family history of premature heart disease
-Age: men > 45 and women > 55
**ATP III: Diabetes is regarded as a CHD risk equivalent
-If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10 year CHF risk (framingham tables): >20% CHD risk equivalent, 10-20%, <10%

Question 5

Treatment of Hyperlipidemia

Answer 5

• Initiate Therapeutic lifestyle changes if LDL is above goal
• TLC diet: Saturated fat <200, Consider increased viscous soluble fiber and plant sterols -Weight management -Increased physical activity
• Consider adding drug therapy if LDL exceeds levels / goals: HMG CoA reductase inhibitors (statins)

Question 6

Treatment with Statins

Answer 6

-Statins block the action of an enzyme that controls the making of cholesterol.
-This means the liver makes less cholesterol
-Statins are the most effective at lowering LDL
Side effects:
-Myopathy (muscle pain or weakness)
-Increase liver enzymes
-Check liver funtion tests / ALT at baseline and then 6-8 weeks following initiation of therapy. Also recheck if increased dose and annually

Question 7

Bile acid Sequestrants

Answer 7

• Welchol, Colestid
• These bind with cholesterol rich bile acids in the bowel; as a result more cholesterol in the blood is converted into bile acids and eliminated in the feces and will lower LDL
• 2nd choice after all statins have been tried.

Question 8

Cholesterol Absorption Inhibitors

Answer 8

• Ezetimibe (zetia)
• This is the only agent in this family
• It works by blocking the absorption of cholesterol from the small intestine.
• Recommendations are to utilize statins first, then consider this agent if need further LDL reduction
• Doesnt reduce CV attacks – doesnt improve outcomes

Question 9

Treatment of Hypertriglycerdemia

Answer 9

Diet:

• Decrease sugar intake, carbohydrate intake
• Decrease ETOH intake

Fenofibrates: Tricor, Gemfibrozil

• Fibrates are primarily used for lowering trigylcerides
• Interaction with statins

Fish oil:

• recommend up to 7-8 grams per day
• Lovaza: Prescription form of fish oil

Question 10

Treatment of HDL deficiency

Answer 10

• Since the AIM-high trial was published, showing that Niaspan / Niacin does not reduce cardiovascular events (MI, stroke).
• We knew that niacin which is a form of vitamin B and in large doses could raise HDL. It can also lower LDL and triglyceride
• Common side effect is flushing.
• Aerobic exercise is the best way to raise good cholesterol.